One in five Americans die using intensive care (ICU) services despite a dominant cultural preference for dying at home. Blacks, especially those with cancer, are more likely to die in an ICU than whites, despite the fact that the majority of black elders have a preference against aggressive end-of-life treatment. For patients with end-stage cancer, seeking or deferring ICU admission is a critical single-event decision. While there is some evidence that blacks may be more likely to prefer aggressive life-sustaining treatment than whites, race-based differences in communication around end-of-life ICU use likely also contribute to existing disparities. Previous studies of physician decision making for common medical conditions have demonstrated race-based differences in diagnosis and treatment, ranging from overt prejudice, stereotyping and discrimination to the application of rules of conditional probability in the context of uncertainty. The goal of the proposed study is to enhance understanding of decision-making processes that impact end-of-life ICU use and factors which contribute to existing racial disparities in end-of-life ICU use. Our three specific aims are: 1) To test the effect of patient race on physician decisions to recommend ICU admission for a patient with end-stage cancer using high-fidelity simulation. 2) To test whether and how patient-provider communication mediates the effect of patient race on physician ICU admission decisions using qualitative content analysis of simulation encounters. 3) To explore the causes of race-based differences in ICU admission decision-making. A better understanding of physicians'decision-making processes and how they may contribute to a mismatch between patient preferences and end-of-life treatment could be used to design interventions to improve physician behavior. Public Health Relevance: The relevance of the proposed project to public health derives from a better understanding of how physicians contribute to racial variations in intensive care use at the end of life. The proposed project will be a success if can document differences in treatment decisions for black versus white simulated patients and generate hypotheses explaining these observed differences. Future work might include testing these hypotheses and developing educational modules for physicians aimed at improving their ability to make patient-centered decisions for critically ill patients with end-stage cancer.